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Patient Registration Form.

Soffer Dentistry Jersey

South Jersey, 132 White Horse Pike,Clementon, NJ, 08021(856) 783-4949

Patient Details( * mandatory to fill )

First Name*

Last Name*

Middle Name

City*

State*

Zip*

Date Of Birth*

Address*

Gender*

Marital Status*

Social Security Number*

Driving License Number

Contact Information( * mandatory to fill )

Email*

Home Phone Number

Cell Phone Number*

Work Phone Number

Work Extension Number

Responsible Party's Information( * mandatory to fill )

Address*

City*

State*

Zip*

Home Phone Number

Cell Phone Number

Work Phone Number

Work Extension Number

Social Security Number

Driving License Number

Emergency Contact Information( * mandatory to fill )

Name

Phone Number

Primary InsuranceDetails( * mandatory to fill )

Relation To Patient

Name Of Insured

Insured SSN

EmployerName

Insured Person's Address

DOB of Insured

Group Number

REM. BENEFITS

REM. DEDUCT

Insurance Company

Insurance Company Address

Insurance Company City

Insurance Company State

Insurance Company ZipCode

Medical History( * mandatory to fill )

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could h

Are you under a physician's care now?

yes

no

If Yes,

Have you ever been hospitalized or had a major operation?

yes

no

If Yes,

Have you ever had a serious head or neck injury?

yes

no

If Yes,

Are you taking any medications, pills or drugs?

yes

no

If Yes,

Do you take, or have you taken,phen-fen or Redux

yes

no

If Yes,

Have you ever taken Fosamax, Boniva,actonel or any other medications containing bisphosphonates?

yes

no

If Yes,

Are you on a special diet?

yes

no

Do you use tobacco?

yes

no

Do you use controlled substances?

yes

no

If Yes,

Women, are you?

Pregnant/trying to get pregnant?

Nursing?

Taking oral contraceptives?

Are you allergic to any of the following?

Aspirin

Pencillin

Codeine

Acrylic

metal

Latex

sulfa drugs

Local anesthetics

Other

If Yes,

Do you have, or have you had, any of the following?

AIDS/HIV Positive

Yes

No

Alzheimer's Disease

Yes

No

Anaphylaxis

Yes

No

Anemia

Yes

No

Angina

Yes

No

Arthritis/Gout

Yes

No

Artificial Heart Valves

Yes

No

Artificial Joints

Yes

No

Asthma

Yes

No

Blood Disease

Yes

No

Blood Transfusion

Yes

No

Breathing Problems

Yes

No

Bruise Easily

Yes

No

Cancer

Yes

No

Chemotherapy

Yes

No

Cold sores / Fever blisters

Yes

No

Congenital heart disorder

Yes

No

Convulsion

Yes

No

Cortisone medicine

Yes

No

Diabetes

Yes

No

Difficulty Breathing

Yes

No

Drug Addiction

Yes

No

Easily Winded

Yes

No

Emphysema

Yes

No

Epilepsy or Seizures

Yes

No

Excessive Bleeding

Yes

No

Excessive Thirst

Yes

No

Fainting spells / Dizziness

Yes

No

Frequent Cough

Yes

No

Frequent Diarrhea

Yes

No

Frequent Headaches

Yes

No

Genital Herpes

Yes

No

Glaucoma

Yes

No

Hay Fever

Yes

No

Heart Attack / Failure

Yes

No

Heart Murmer

Yes

No

Heart Pacemaker

Yes

No

Heart Trouble / Disease

Yes

No

Hemophilia

Yes

No

Hepatitis A

Yes

No

Hepatitis B or C

Yes

No

Herpes

Yes

No

High Blood Pressure

Yes

No

High Cholesterol

Yes

No

Hives or Rash

Yes

No

Hypoglycemia

Yes

No

Irregular Heartbeat

Yes

No

Kidney Problem

Yes

No

Leukemia

Yes

No

Liver Disease

Yes

No

Low Blood Pressure

Yes

No

Lung diseases

Yes

No

Mitral Value prolapse

Yes

No

Osteoporosis

Yes

No

Pain in Jaw Joints

Yes

No

Parathyroid Disease

Yes

No

Psychiatric Care

Yes

No

Radiation Treatments

Yes

No

Recent Weight Loss

Yes

No

Renal Dialysis

Yes

No

Rheumatic Fever

Yes

No

Rheumatism

Yes

No

Scarlet Fever

Yes

No

Shingles

Yes

No

Sickle Cell Disease

Yes

No

Sinus Trouble

Yes

No

Spina Bifida

Yes

No

Stomach/Intestinal Disease

Yes

No

Stroke

Yes

No

Swelling of Limbs

Yes

No

Thyroid Disease

Yes

No

Tonsillitis

Yes

No

Tuberculosis

Yes

No

Tumors or Growths

Yes

No

Ulcers

Yes

No

Venereal Disease

Yes

No

Yellow Jaundice

Yes

No

SIGNATURE *

(Please click below to draw/upload sign)

(Your IP Address :
IP:34.236.153.51 )

Office Policies( * mandatory to fill )

Welcome to our practice. We appreciate that you trust us with your dental care, and we promise to do our best to honor that trust by providing the quality of dental care you deserve. It is our priority to make you feel comfortable in our office and ensure all your visits are pleasant experiences. Please don't hesitate to reach out with any concerns.

We prefer not to consider ourselves a clinic. Our office is a warm, friendly environment. We schedule time for "you," exclusively. That being said, if you cannot keep a scheduled appointment, please give us 24–48 hours notice so that someone else may use your appointment time. Failure to do so will result in a $35 charge.

We have 3 payment options.

1) Payment by cash or check as treatment progresses

2) Payment by credit card or debit card

3) Extended payment plans (with approved credit).

We will file your dental claims for you and follow up on them. We will make every effort to help you receive your maximum legal insurance benefit. Keep in mind, no insurance pays all dental costs. It is customary that you are responsible for payment at the time of service.

With recent advances in dentistry, we are able to give you the best possible care. Dental treatment has become so thorough that patients may keep their natural teeth for a lifetime, if patients also do their part. In addition, we provide high quality services such as porcelain veneers, bleaching, and bonding that will improve your smile. Dental implants are available to replace missing teeth and provide you with the confidence to chew and smile more comfortably.

Working with us ensures a healthier mouth now and in the future. We maintain a well-organized scheduling system, which reminds patients about cleanings and maintenance requirements as needed. It is our mission to provide you with excellent dental care that is durable and attractive, maintaining careful attention to your comfort.

We thank you again for the confidence you have placed in us. You may rest assured that we will do everything in our power to make your visits and those of your family and friends as pleasant as possible.

SIGNATURE *

(Please click below to draw/upload sign)

(Your IP Address :
IP:34.236.153.51 )

HIPPA Form( * mandatory to fill )

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters.)

HIPPA Form( * mandatory to fill )

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail(e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, You may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer:

Telephone:

Fax:

E-Mail:

Address:

Acknowledgement I, hereby acknowledge that I have read and fully understand the contents of this document, and I have been given the opportunity to ask any and all questions.